COMMENTARY

Clostridium difficile Infection: 5 Things to Know

David A. Johnson, MD

Disclosures

September 10, 2018

3. A New Agent Could Prevent Recurrence

In 2017, the US Food and Drug Administration approved another drug option for patients who are at high risk for a recurrence of CDI: bezlotoxumab, a human monoclonal antibody to C difficile toxin B. Bezlotoxumab is not an antimicrobial; therefore, it is indicated only for adults who are being treated with an antibiotic for CDI and are at risk for a recurrence. Results from two large randomized, controlled studies demonstrated a rate reduction of approximately 10% for bezlotoxumab compared with placebo.[11] It is administered as a single infusion over 1 hour. Bezlotoxumab does carry a precaution about use in patients with heart failure. Cost could be a barrier to the use of bezlotoxumab, and more research is needed to compare the cost-effectiveness of this drug with that of other treatments for CDI.

4. Recurrent Disease Is More Common Than You Might Think

Recurrent CDI occurs in approximately 25% of patients who initially responded to treatment, and can be caused by a relapse from the original infecting strain or reinfection with a new strain.[12]

Recommended treatments of a first CDI recurrence include a 10-day course of oral vancomycin followed by a tapered regimen of vancomycin: 125 mg twice daily for 7 days, then 125 mg once daily for 7 days, and finally, 125 mg every 2 to 3 days for 2 to 8 weeks.[7] Fidaxomicin 200 mg twice daily for 10 days is an alternative if oral vancomycin was used for the first episode. Metronidazole is not recommended for recurrent disease.

Patients with recurrent disease, and their families, also should be instructed on high-level disinfection of the entire bathroom at home. This includes mechanical disruption of C difficile spores in the toilet bowl using a toilet brush and cleaning surfaces with wipes that contain bleach. All toothbrush heads and water glasses should be replaced. High-level cleaning of ancillary oral devices (eg, dentures, mouth guards) should also be performed

While probiotics have been used to reduce recurrence, they are not recommended by the most recent guideline.[10] Some evidence shows that probiotics taken with antibiotics may be associated with a lower risk for abdominal cramping and nausea but not recurrence of CDI.[13]

Antibiotic stewardship is key to prevention. The overuse of quinolones can cause CDI; this class of antibiotics should be used only in the absence of an alternative.[7] The use of proton pump inhibitors (PPIs) and risk for CDI has been an area of controversy, but the evidence does not support a recommendation that PPIs be discontinued as a method for preventing recurrent disease.[7,14]

5. The Latest Scoop on Poop for CDI

Fecal microbiota transplantation (FMT) is indicated for patients who have failed antibiotic treatments, have had multiple (ie, two or more) recurrences of CDI, or have severe disease complications. To minimize any transmissible infections or even metabolic and inflammatory changes relative to the transfer of fecal microbiota, the stool donor should be appropriately screened.

Most experts recommend a 3- to 4-day "induction course" of oral vancomycin for patients who are not already being treated for CDI to reduce the burden of vegetative CDI prior to FMT.[7]

Although most research has looked at colonic instillation of fecal microbiota (typically by colonoscopy), upper gastrointestinal administration has been shown to be effective.[15] Consultation with local clinicians who have expertise in this procedure should be considered.

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